Make Any Changes in Name and Address Directly on the Mailing Label

Annual report of wood purchased or acquired during the year ended Dec. 31, 2016

Name: Position or title:

Phone number of person to contact regarding the information contained herein:

Federal I.D. number: State I.D. number:

Make any changes in name and address directly on the mailing label.

General instructions 1. Minnesota Statutes § 176.130 provides that all wood mills that acquire more than 5,000 cords in a calendar year, either inside or outside of Minnesota, shall file a report setting forth the number of cords purchased and pay an assessment of $ .30 per cord of wood greater than 5,000 cords. The report and assessment are due on or before Feb. 15 of the following year. For audit purposes, this report must be filed even if fewer than 5,000 cords were acquired and no assessment is due.

2. The report should include all wood acquired either inside or outside the state of Minnesota, as well as wood acquired from sources employed by the mill operation. Mills that operate in more than one location should file one consolidated report to include the total wood acquired by all operations. Do not file separate reports for each location.

3. The report and/or assessment payment must be received or postmarked on or before Feb. 15. Penalties will be assessed for all reports/payments that are not received or postmarked by the due date. Minnesota Statutes § 176.129 provides a penalty of up to 15 percent of the amount of the assessment due, but not less than $1,000, in the event the report and/or assessment are not timely filed. The penalty for filing a late report with no assessment due is $200.

4. Requests for extensions will be granted only for reasons that are beyond the control of the mill and must be received or postmarked on or before the due date, Feb. 15.

5. Completed reports should be mailed to: Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road N. St. Paul, MN 55155

For more information, call John Kufus at (651) 284-5179. List all wood acquired (by species) during the period from Jan. 1 through Dec. 31, 2016.

Weight (pounds) Cut logs or Whole Board Species tree length tree chips feet Cords Aspen Ash Balm Basswood Birch Cottonwood Elm Maple Oak Other hardwoods Cedar Pine Spruce Tamarack Other softwoods Total Conversion Factor 4500 6000 500 N/A 11. Equivalent number of cords purchased (total divided by (a) (b) (c) (d) conversion factor) 22. Total cords purchased (a + b + c + d) 3Less: 5,000 cord exclusion (5,000) 3. Assessable number of cords purchased 44. Assessment payable (Line 3 x .30) 5(Make check payable to Minnesota Department of Labor and Industry and attach to front page of report.)